MEDICARE: M M ORTHODONTICS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	21086	TX
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	23783	TX
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20402	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1312131	OTHER	TX	UNITED CONCORDIA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356351456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M M ORTHODONTICS PA

Provider Business Mailing Address
First Line	:	6735 FM 78
Second Line	:	SUITE 102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78244-1367
Country	:	US
Telephone Number	:	210-667-2929
Fax Number	:	210-661-2575

Provider Business Practice Location Address
First Line	:	6735 FM 78
Second Line	:	SUITE 102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78244-1367
Country	:	US
Telephone Number	:	210-667-2929
Fax Number	:	210-661-2575

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. DIANA T MALONE
Credential	:	D.D.S.,M.S.
Telephone Number	:	210-667-2929

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/12/2008

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Directions to “M M ORTHODONTICS PA ” Practice Location

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